Right After Birth, Within the First Hour of Life, Normal Infants Have a Prolonged Period

GETTING BREASTFEEDING STARTED with EVIDENCE-BASED CARE

"Right after birth, within the first hour of life, normal infants have a prolonged period of quiet alertness…during which they look directly at their mother's and father's face and eyes and can respond to voices. It is as though newborns had rehearsed the perfect approach to the first meeting with their parents."

Marshall Klaus, MD

I.Evaluating Our Care

A.Looking at traditions

1.Birthing environment

2.Birthing practices

3.Priority on assessment & recovery tasks

4.Separating baby and mother

B.Do labor medications influence feeding success?

1.Jury still out

2.Narcotics during labor (Crowell 1994)

a.Decrease alertness

b.Lower neurobehavioral scores

c.Inhibit suckling

d.Delay effective feeding

3.Effect of pain meds in labor (Riordin et al 2000)

a.Babies whose mothers received both epidural plus IV narcotics had lowest IBFAT Score

b.No effect on duration when measured at 6 weeks

4.Labor meds disturb newborn behavior (Ransjo-Arvidson 2001)

a.Pudendal, epidural or pethidine

b.Infant massage-like hand movements less frequent

c.Fewer infants touched nipple

d.Fewer licking or sucking movements

e.Average time to first feeding >150 minutes compared to 79 minutes in group with no medication

II.Making Breastfeeding a Priority at Birth

A.Most healthy, term babies nurse within first 1-1.5 hours post birth

1.Sucking reflex peaks within first few hours of life

2.Reflex appears to be less acute if this time missed

B.Necessary care can still be done

1.Mothers learn from their care in labor

2.Vital signs can be done skin to skin

3.Necessary interventions can be done skin to skin

4.Weight can be done after a feeding

5.Bathing can wait and be done humanely

C.Skin to skin care: fluff or science?

1.Keep baby in skin contact with mother and watch for feeding cues

a.Skin to skin and feeding promotes a safe environment for new infant

1)Keeps baby warm

a)Infants who are kept skin to skin in first 90 minutes have higher axillary and skin temperature

b)Babies have continued protection against hypothermia after skin to skin in first 24 hours

2)Colonizes the skin, respiratory and intestinal tracts of the baby soon after birth

3)Reduces pain

a)Pediatrics, April 2002

(i)30 full-term, breastfed infants

(ii)Intervention group were held and breastfed during heel lance and blood collection

(iii)Control group experienced the same test while swaddled in their bassinets

(iv)Crying and grimacing were reduced by 91%. Heart rate was also substantially reduced by breastfeeding

4)Babies kept skin to skin cry less

5)Heart rate more stable, BP lower, temp higher -> decreased stress

b.Skin to skin leads to predictable patterns of newborn

1)Relaxation

2)Cooing sounds

3)Early breastfeeding behavior

a)Baby crawls to breast

b)Baby opens and closes hands (like a kitten)

c)Nipple and areola make good target

d)Mouth movements, salivation

e)Open mouth if touches anything

f)Infant's own rooting important, even if we need to assist with feeding

c.Lovely way to celebrate and to comfort mother and baby

1)Mothers will "talk" to baby - high pitched, attentive

2)Exploration of baby with fingertips

3)Need for a period of quiet, sensitive exploration

4)Important role of father as protector and helper in feeding baby

III.Effects of our Care on Milk Production

A.Prolactin – from the anterior pituitary gland

1.Helps women respond to stresses of perinatal period

2.After hormones of pregnancy, suckling is the most effective stimulus for prolactin release

3.Direct stimulation of the nipple is necessary for prolactin release

4.Stimulates alveoli (milk-producing cells) to secrete milk

8.Enters the alveolar cells only when they are tall and column-shaped and have minimal milk in the lumen

5.Binds to receptor sites on the alveoli

a.Receptor sites likely laid down in pregnancy

5)Estrogen, progesterone, placental lactogen

d.Frequent early breast stimulation in first two weeks post partum may increase sensitivity of receptors to prolactin

9.Frequent feedings keep prolactin levels high in the mother’s bloodstream

B.Oxytocin - from the posterior pituitary

1.Produced in the hypothalamus

2.Oxytocin in the bloodstream

a)Is released with nipple stimulation

b)Oxytocin is also released by visual, auditory, tactile, and psychological stimuli, with sequential effects

1)Warmth, massage, skin contact, hand motions of the newborn

2)Thinking about baby, hearing a baby cry

3)All release more and more oxytocin into brain

4)Baby massages the breast

a)When diagrammed, matching oxytocin surges with hand movements

b)Hand movements had more influences on oxytocin rises than the suckling

4.Oxytocin in the brain

a.It affects every body system.

1)Breast

2)GI tract

3)Liver

4)Heart

b.Results in effects opposite to “fight or flight” response with lifetime effects

1)Blood pressure drops

2)GI hormones increase

3)Skin sensitivity increases

4)Brain activity becomes calm and introverted

5)Mother becomes sleepy and calm

c.Oxytocin likely relates more to pain relief in labor than endogenous endorphins

1)Stimulates endorphins

2)Increases pain threshold

3)Has long-lasting effects on pain tolerance

d.Correlation with number of oxytocin peaks and physical and emotional traits

1)Women who have high levels of oxytocin

a)Produce more milk

b)Breastfeed longer

c)Are more tolerant of repetitious, boring tasks

d)Demonstrate more “social” behavior – better listeners

e)Women become more social and retain those traits if they continue breastfeeding

5.Relationship of oxytocin and gastrointestinal hormones (“Eating and bonding are linked”)

a.Oxytocin stimulates the release of gastrointestinal hormones such as insulin, cholecystokinin, somatostatin, and gastrin

b.GI hormones stimulate intestinal villi, increasing surface area for absorption of nutrients

e.Induces satiety, post-feeding sedation and sleep.

f.Helps infant absorb nutrients and regulate caloric intake

g.Creates contentment in both mother and baby

6.Menopausal symptoms likely related to loss of oxytocin receptors

a.Sleep disturbances, GI disturbances, cardiac problems, loss of feeling of well-being, etc.

IV.Does Our Practice Influence When Milk “Comes In”?

A.Lactation - three stages:

1.Lactogenesis Stage I

a.Production of colostrum by the third month of gestation

2.Lactogenesis Stage II

a.Typically occurs 24-48 hours post partum

b.Women aware of process 24-36 hours after it has begun

1)Mean time of awareness 67 hours pp

2)Women should be aware by 72 hours pp

c.Volumes increase to ~500ml/24 hours by day 5

3.Lactogenesis Stage III - the process of ongoing milk secretion, prolonged as long as milk is removed from the gland on a regular basis.

B.Effects on timing of lactogenesis

1.Delayed by:

a.Labor pain medications Effect of pain meds on lactogenesis (Hildebrandt 1999)

1)Shortest time to lactogenesis was 44 hours in multip with vaginal birth and no medication

2)6 hours longer if cesarean section

3)11 hours longer if primip

4)13 hours longer if sedative or pain medication given in labor

5)Effects were cumulative

b.Cesarean birth

c.Unscheduled Cesarean birth

1)?less endogenous oxytocin

2)?less activation of early receptors when minimal uterine and breast contractions and many postpartum distractions

3)Importance of early breast stimulation and early feedings for C-section moms

a)Breastfeeding started as soon as mother returns to her room

b)No reason to delay feedings

c)Manage pain

d.Prolonged second stage of labor (>1 hour)

e.Delivery of infant >8 lbs

f.Primiparity

g.Heavy/obese body build

h.Diabetes

i.Exclusive formula feeding

j.UC Davis study – Pediatrics 2003

1)280 mother-baby pairs

2)IBCLC managed

3)Delayed onset of lactogenesis

a)Primip

b)Supplementation in first 48 hours

V.Is There Evidence to Justify Early Supplementation of Newborns?

A.Babies who do not need supplementation

1.A term, healthy sleepy baby with few feedings during the first 48 hours.

2.The disorganized infant who won’t latch

3.Nighttime fussiness or constant feeding for several hours where baby is content and satisfied while on the breast, fussy if off.

4.Tired mothers

B.Medical indications for supplementing newborns

1.> 10% weight loss in first 24 hours

2.Supplementation for early dehydration (fever alone can be a sign)

a. Fever in a term, otherwise healthy infant

b.A bit of water may be all that is necessary

3.Supplementation for illness resulting in separation of infant and mother

a.Infant who is unable to feed at the breast (e.g. prematurity <32-33 weeks

b.Congenital malformation, illness making BF impossible

c.Mother illness requiring transfer to hospital

d.Unresolved hypoglycemia

VI.Almost Premature – may need supplements, maybe not

Infants born between 35-40 weeks gestation frequently present a unique dilemma for those who are caring for them. They are often well-developed, vigorous at birth, and their behaviors frequently mimic those of term, healthy infants. However, missing out on the last few weeks of in-utero gestation may result in a more subtle immaturity that requires vigilant assessment and care to prevent subsequent problems. Experience shows that these infants are more vulnerable to hypothermia, hyperbilirubinemia, progressive lethargy, poor feedings over time and a greater than 10 percent weight loss if allowed to breastfeed on demand without intervention. Our goal is to prevent these complications without creating unnecessary complexity and intervention and without creating unnecessary anxieties for the parents.

A.Prevention of hypoglycemia/hypothermia

1.Same as a full term newborn

2.Minimizing environmental stressors

3.Keep baby in continuous skin contact with mother or father and watch for feeding cues

a.May be more subtle or absent with these babies

b.If baby demonstrates “term” behaviors, don’t be fooled

4.Get the baby fed! - Colostrum is perfect food

a.Appropriate for the size of the newborn’s stomach

b.Usually sufficient to prevent or correct hypoglycemia in both preterm and healthy term infant

c.Frequent drops of expressed colostrum if baby feeding poorly at breast

1)Follow feeding with additional drops of expressed colostrum placed on tongue

2) TB or 5-10cc syringe

3)Hand expression will be necessary to collect milk)

d.If blood sugar not maintained with colostrum

1)May need to add dextrose water to colostrum to provide volume or sugar

2)Formula next choice if breastmilk not available

3)If blood sugar not maintained, then intravenous glucose with nursery transfer

B.Ensuring an Adequate Milk Supply/Adequate Intake

1.Feed baby - at breast whenever possible

a.Some controversy about how often to feed

b.Some feel these babies do better with feeds every 4 hours

c.Others feel it best to feed every 2-3 hours

d.Watch for feeding cues

e.Frequent breast contact, even without feeding

2.Stimulate breasts in addition to baby latching

a.Hand expression, regardless of how baby feeding

b.If available may begin use of breast pump in addition to hand expression

c.Hand express and/or pump ~q3hours

d.Use milk for feeding baby or start to collect and freeze

e.Create and communicate feeding plan

3.Positioning & latch

a.Cross cradle, transition hold

b.Upright, as these babies are prone to reflux

c.Between feeds, best kept upright, skin to skin

d.In sling at home

4.Advantages of nipple shields with prematurity / immaturity

a.Infant lacks fat pads in cheeks

b.Unable to maintain muscle contraction for long periods of time

c.May have dysfunctional suck

d.Nipple shield provides stable teat, no muscle fatigue

e.Helps baby to maintain latch

f.Baby gets fed and gains weight while working on BF

g.Keeps baby "breast oriented"

h.Parents not overwhelmed with equipment

C.What Happens Next?

1.Daily weights

2.Observation for hyperbilirubinemia

3.Car seat challenge before discharge

4.Daily weights

5.May benefit from scale at home – but needs to be accurate

6.Follow-up Care

a.Immediate infant/maternal assessment

b.Reassessment of discharge feeding plan

c.Communication with health team

d.IBCLC

1)On-going feeding assessments

2)Maternal/parental coping

e.Connection with mother support group

LLLIreland04

Molly Pessl, BSN, IBCLC

402 Detwiller Lane

Bellevue, WA 98004

1.425.455.3231

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